Articles

Gratitudejournalscanimprovenursesmentalwell-being.pdf

58 l Nursing2022 l Volume 52, Number 12 www.Nursing2022.com

Abstract: With nursing burnout on the rise, effective self-care interventions such as gratitude journals are needed to help nurses cope with symptoms of burnout. Gratitude journals can support nurses’ emotional health by improving stress management and offering an opportunity for overall self- reflection.

Keywords: gratitude journal, journaling, mental health, positivity, self-care

BY KELLY CUMELLA, MSN, RN, FNP-C

Gratitude journals can improve nurses’ mental

well-being

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Since the onset of the pandemic, nurses throughout the US have been feeling the effects of work burnout. The World Health Organization de- fines burnout as a syndrome that results from chronic workplace stress that has not been effectively man- aged.1 Burnout symptoms can range from physical feelings of exhaustion and low energy to reduced profes- sional efficacy.1 A 2021 study that surveyed 1,834 nurses found that 54% of the respondents were experi- encing burnout.2 The study also re-

vealed a strong correlation between burnout and nursing turnover.2 With high rates of nursing turnover, care is more disjointed and teamwork for best patient outcomes becomes more difficult.2 Effective interventions are needed to help support mental health practices among nurses to mitigate high levels of burnout. Oth- erwise, not only are individual nurs- es at risk but the healthcare system may also be compromised.

When nurses reflect on their rea- sons to pursue this career path, often

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risk factors for a stroke or myocardial infarction. Long-term elevated corti- sol levels can increase the likelihood of obesity and the amounts of depos- ited adipose tissue.5 This means that the body is in a constant state of flight-or-fight mode, which can be physically and mentally overwhelm- ing. This constant state of chronic stress causes increased fatigue and eventually, burnout.5

Impact of burnout on nurses Burnout negatively affects nurses and also team morale, patient satisfac- tion, patient outcomes, and even pa- tient mortality.5 Symptoms such as reduced physical and emotional en- ergy, fatigue, headache, and insomnia have been shown to increase absen- teeism and turnover rates.2 Nurses with poor mental and physical health are up to 71% more likely to report making a medical error compared with those in better health.2 These issues make burnout a costly prob- lem for healthcare organizations as well. Of note, organizations that im- plement burnout interventions have reported increased nursing retention, reduced turnover rates, and higher levels of patient satisfaction.3

Benefits of gratitude intervention In the past decade, there has been growing research on positive psycho- logical interventions as a strategy to improve mental health, with the most well-known being a gratitude inter- vention.6 Gratitude is the quality of being thankful, the readiness to show appreciation, and to then return that kindness.7 When the burden of pa- tients who are critically ill, endless tasks, lack of staff, and inadequate pay cloud a nurse’s mind, it can be challenging to find aspects of work to be thankful for. Gratitude journaling has been used to improve a grateful disposition among nursing students, and even encourages the adoption of a positive viewpoint during stressful

situations.4 Journaling allows for re- connection with various thoughts and a comprehensive review of new experiences, both positive and nega- tive. By reviewing these lived experi- ences, one gains new insights, often developing a new perspective and a way to reevaluate a difficult experi- ence.2

Gratitude journals come in many shapes and sizes, including written and electronic formats. The basic in- troduction to keeping a gratitude jour- nal is to write down two to five things you are grateful for, two to three times per week. When working on this practice, try to express gratitude for both small and big things and experi- ences.8 Prompts can also help stimu- late reflection on different aspects of life—to allow for a broader reflection.

Do gratitude journals work? Various studies on the impact of gratitude journals have found that this practice helps provide perspec- tive, stress management, and self-re- flection.9 In a study involving healthcare practitioners, the use of gratitude journals as little as twice per week has resulted in lower re- ported stress levels and depressive symptoms after 1 month and were maintained at the 3-month follow- up after intervention.10 In a study conducted in Korea in 2020, 4th-year nursing students who kept a grati- tude journal for 8 weeks reported a more balanced effect both profes- sionally as well as academically.4

Other findings included the ability to observe daily life more closely, and an increased ability to intention- ally remember to be more grateful.4

A 2019 study investigated the GRACE training program (a health- care professional support program), which included journaling and mindfulness components to improve healthcare workers’ well-being and stress response.11 This study found that the participants who attended the training for over 2 years had

they recall positive moments when they were able to be present and help a patient through a very difficult time or a time when they formed a deep connection with a patient’s family.3

However, less reflection occurs about the moments of witnessing horrific deaths, complicated family grieving, and the personal burden taken on by the loss of a patient.3 Though these events can be initially challenging to process, through reflecting and jour- naling, nurses as well as nursing stu- dents may identify what they did well professionally at this moment or what they may change in the future. This allows for closure and can bring a positive perspective to a difficult situation.4

This article discusses the benefits of gratitude journaling to support nurses and healthcare organizations in promoting meaningful mental health practices for nurses.

Endocrine stress response Stress has a major impact on our en- docrine system, specifically hormon- al changes that can have a long-term effect on an individual’s overall health (see Hypothalamic-pituitary axis and stress). If the brain perceives something as a stressor, the hypo- thalamus releases corticotropin- releasing hormone (CRH), which travels to the pituitary gland, trigger- ing the release of adrenocorticotropic hormone (ACTH). This hormone travels to the adrenal glands, prompting the release of cortisol.5

When the threat passes, cortisol lev- els then fall. The parasympathetic nervous system then will decrease the stress response in the body. But what happens if the parasympathetic system is unable to lessen the stress response? Chronic low-level stress keeps the hypothalamic-pituitary axis running; this is not healthy for the body long term.5 Persistent epi- nephrine release can damage blood vessels and arteries, increasing BP and consequently increasing cardiac

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significantly increased Hospital Con- sumer Assessment of Healthcare Providers and Systems (HCAHPS) scores compared with the units that did not receive the GRACE train- ing.11 The study reported that higher levels of healthcare professional stress and burnout are associated with a decrease in effective patient- centered care and reduced effective communication with both other members of the healthcare team and patients.11 Another qualitative study that examined nursing students’ ex- periences of journaling during the pandemic found gratitude to be a common theme of reflection. Many found that sharing experiences in- creased their overall feelings of grati- tude and allowed for increased feel- ings of gratitude toward coworkers. The sharing of journals allowed for the fostering of social and profes-

sional bonds.4,6 The benefits of grati- tude journals have also extended past the emotional realm. Physical benefits such as improved sleep quality, increased motivation for physical exercise, and decreased physical symptoms of stress such as fatigue have also been reported.4

Starting a gratitude journal Gratitude journals can be imple- mented to help nurses develop im- proved stress management tech- niques, promote overall happiness, and provide an outlet for nurses to express their feelings. It is low-cost and requires a low time commitment, with an average journaling session requiring 10-15 minutes, and a jour- naling frequency of about as little as twice per week.8 Initiating the reflec- tion process and starting a gratitude journal effectively can be difficult.7

Nurses should consider their per- sonal preferences and try different journaling methods, such as using guided questions or an electronic journal format. Nurses are encour- aged to take a moment to reflect on simple everyday pleasures, the peo- ple in their lives, their strengths or talents, or experiences of kindness.7

Consider this example written by a nurse after a long day in the ED with an eight-patient assignment includ- ing a patient with a gunshot wound and an older adult at the end of life. The nurse used a prompted gratitude journal specifically for nurses that asked her to identify three things to be grateful for that day:

Although there were many challenges during this grueling shift, there are mo- ments where the gifts of today shine. • I am thankful for being able to contact my older patient’s husband and help co- ordinate with social work to allow him to be at her bedside as she passed. He ex- pressed that this was his wife’s wish, and I am so happy I could help fulfill this for them both. • I am grateful for having a technician to help me with vital signs today, this is not always the case. • I am grateful to have a strong trauma team alongside me today to help stabilize the patient with a gunshot wound quickly.

Being able to clearly identify three things that she was grateful for helped shift the nurse’s focus to the positive parts of her day and reminded her of the good she was able to accomplish and how she was a part of an impor- tant team.

Professional organization support Professional organizations offer tools, programs, and resources to support nurses and healthcare facilities in the development of self-care programs for their nursing staff. The American Nurses Association (ANA), for ex- ample, recognizes the strain nurses are putting on not only their physical but mental health, especially during

Hypothalamic-pituitary axis and stress

The hypothalamic-pituitary axis is a neuroendocrine pathway that mediates a response to stressors. Dysregu- lation of the system can result in an unrelieved stress response and stress-related disorders. Source: Donnelly- Moreno LA, Moseley B. Timby’s Introductory Medical-Surgical Nursing. Philadelphia, PA: Wolters Kluwer Health; 2021.

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the COVID-19 pandemic. The phil- anthropic arm of the ANA, the Ameri- can Nurses Foundation, launched a national well-being initiative that in- cludes Narrative Expressive Writing.12

Writing is a proven and effective tool for building resilience, improving mindfulness, and reducing psycho- logical distress. In this 5-week pro- gram, nurses respond anonymously to COVID-19-related writing prompts. A certified responder reads individu- al’s submissions and provides confi- dential feedback.12 The American Association of Nurse Practitioners and the American Nurses Holistic Association also recognize journaling as a proven tool to improve mindful- ness and reduce stress.12

Conclusion Gratitude journals have been shown to be an effective, low-cost tool to support self-care and reduce the ef- fects of burnout for healthcare profes-

sionals. With its low time commit- ment, it is also a realistic intervention for busy nurses. Gratitude practice has been shown to benefit healthcare organizations as well. To effectively care for patients, nurses must also ensure their physical and mental well-being, and using gratitude jour- nals can be a positive step toward doing just that. ■

REFERENCES

1. World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. 2019. www.who.int/ news/item/28-05-2019-burn-out-an-occupational- phenomenon-international-classification-of-diseases.

2. Melnyk BM, Kelly SA, Stephens J, et al. Interventions to improve mental health, well-being, physical health, and lifestyle behaviors in physicians and nurses: a systematic review.a Am J Health Promot. 2020;34(8):929-941. doi:10.1177/0890117120920451.

3. Henry BJ. Nursing burnout interventions: what is being done? Clin J Oncol Nurs. 2014;18(2):211-214.

4. Ko H, Kim S, Kim E. Nursing students’ experiences of gratitude journaling during the COVID-19 pandemic. Healthcare (Basel). 2021;9(11):1473. doi:10.3390/ healthcare9111473.

5. Harvard Health. Understanding the stress response. 2020. www.health.harvard.edu/staying-healthy/ understanding-the-stress-response.

6. O’Connell BH, O’Shea D, Gallagher S. Feeling thanks and saying thanks: a randomized controlled trial examining if and how socially oriented gratitude journals work. J Clin Psychol. 2017;73(10):1280-1300.

7. Definition of gratitude. In: Oxford Dictionary. Oxford University Press. www.oxfordlearnersdictionaries. com/us/definition/english/gratitude.

8. Suttie J. How practicing gratitude helps nurses avoid burnout. Am Nurse J. 2021;16(8):48.

9. Moon H, Jung M. The relationship between a disposition of gratitude, clinical stress, and clinical satisfaction in nursing students. Perspect Psychiatr Care. 2020;56(4):768-776.

10. Cheng S-T, Tsui PK, Lam JHM. Improving mental health in health care practitioners: randomized controlled trial of a gratitude intervention. J Consult Clin Psychol. 2015;83(1):177-186. doi:10.1037/a0037895.

11. Victorson D, Sauer C, Horowitz B, Wolf- Beadle J. Development and implementation of a brief healthcare professional support program based in gratitude, mindfulness, self-compassion, and empathy. J Nurs Adm. 2021;51(4):212-219. doi:10.1097/NNA.0000000000001000.

12. ANA. American Nurses Foundation launches national well-being initiative for nurses. 2020. www.nursingworld.org/news/news-releases/2020/ american-nurses-foundation-launches-national- well-being-initiative-for-nurses/.

Kelly Cumella is an instructor of nursing at SUNY Brockport in Brockport, N.Y. She also works as an NP in primary care and the geriatric care setting.

The author has disclosed no potential conflicts of interest, financial or otherwise.

DOI-10.1097/01.NURSE.0000884760.97338.8b

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